A retrospective mortality survey conducted by Doctors Without Borders/Médecins Sans Frontières (MSF) between March 26 and April 8, 2014, found that 8 percent (2,599 people) of the members of the families who took refuge in Sido, in southern Chad, died between November 2013 and April 2104, during a period of persecution targeting the Central African Republic’s (CAR) Muslim minority.

The survey data and the testimonies gathered by MSF teams in Chad and Cameroon highlight the breadth of the violence that the populations experienced both in the CAR and during and after their flight from the country. The Central African refugees who reach Cameroon today are exhausted, sick, and traumatized. Unlike the people who arrived initially, entering the country quickly in January 2014 by convoy or private transportation, those who cross the border today have walked for weeks, if not months, making their way through the western part of the country to escape the violence. Their health and nutritional status is very alarming; nearly one of every two children, for instance, is suffering from malnutrition.

The majority of the Muslim population in the western half of CAR fled in just a few months. A few enclaves, protected by international forces from the hostile armed groups surrounding them, still shelter a few thousand Muslims, although their living conditions are very precarious and they have few prospects of safety.

Today, the populations victimized by the anti-balaka and the ex-Séléka forces still face risks and peril as they try to find safe haven within the country or flee to Cameroon and Chad, where they face a new obstacle since the Chadian government has now closed its border to people fleeing violence in CAR.

1. The Suitcase

Several hundred thousand Muslims have fled abuse and violence in CAR, seeking refuge in Chad, since December 2013.

On December 5, 2013, the anti-balaka, a militia formed to oppose the Séléka opposition force that took control of the country in March 2013, attacked Bangui, CAR's capital, provoking fierce fighting with ex-Séléka forces, leading to many deaths and injuries within the civilian population. Christians are largely seen as supporters of the anti-balaka, while Muslims are considered supported of ex-Séléka groups. People on both sides have thus been and continue to be targets for reprisal attacks that drive them to gather in enclosed sites, such as churches, mosques, and hospitals.

The December 5, 2013, deployment of French forces, which gave priority to disarming and confining ex-Séléka forces, unintentionally helped strengthen anti-balaka groups and allowed them more room to launch attacks against all those they considered supporters of the former rebel coalition. Chadian merchants, members of the Fula ethnic group, and Central African Muslims thus all became targets of systematic reprisals in Bangui and in the western part of the country. While some took refuge in enclaves, others sought to flee the country.

In December 2013, the Chadian government, which had been accused of supporting the Séléka rebels during their initial insurgency, decided to repatriate its “nationals,” who were often the second or even third generation of Chadian immigrants in CAR. This repatriation was carried out by plane (to N’djamena) and truck, under escort of the Chadian army, to Sido. According to the International Organization for Migration (IOM), 101,786 people entered Chad by plane and truck.

Between November 1, 2013, and April 8, 2014, (with a spike in January 2014), more than 26,000 Central African refugees arrived, most by military convoy, in Sido, a Chadian town on the Chad-CAR border. They included Central African Muslims who also seized the opportunity to flee their country on board the trucks. Testimonies from them illustrate the terrifying nature of the journey:

“The anti-Balakas attacked Yaloké and then occupied it. I was in the bush for 20 days with eight other people from my village. People told me that the French army was evacuating Muslims. That’s when I came out of the bush. They took me to the Yaloké mosque and then to the Bangui airport. I stayed there for more than two weeks before joining a Chadian army convoy.”—K., 28, a woman originally from Yaloké. Testimony taken in Chad, February 2014.

“We stayed at the Bouali church for 20 days with 800 other people. The French army protected us until they were replaced by the MISCA [the African-led mission that's been deployed in CAR], which then escorted us to the Yaloké mosque. Then the Chadian army took us to the Bangui airport, where we stayed for three weeks before taking the last convoy to Sido.”—M., 60, a man originally from Bouali. Testimony taken in Chad, February 2014.

“During the attack, we fled into the bush with our neighbors. The husband of one of our older sisters managed to find us and took us to their house in Bonali. From there, we all fled to Bangui in one of the Chadian army convoys.”—Two sisters, around 10, originally from Bossembélé. Testimony taken in Chad, February 2014.

The United Nations High Commissioner for Refugees (UNHCR) initially set up only 294 tents to shelter the new arrivals in Sido, who initially numbered 21,000[1]. While the situation has improved, the humanitarian needs were significantly underestimated at the outset. The massive influx of refugees quickly outstripped the capacity of the humanitarian agencies and local authorities. In addition, all the evacuees were not considered to be Central African refugees, but “returnees;” that is, Chadians who had returned to their country. In short, UNHCR did not take steps to register the families or coordinate aid. As a result, the aid available in most of the reception areas is inadequate and under-funded.

“I have nothing, just the clothes on my back," said the 60-year old man from Bouali. "I would like to go to Cameroon, where I have relatives. We eat only once a day and all we have is the food we received at the Bangui airport.”

A 23-year woman from Bangui said, “I’ve received just one food ration since I arrived. My three-year-old daughter has been sick since we left Bangui." The child was diagnoses with severe acute malnutrition and treated by MSF in Sido.

The number of people in the Sido camp when MSF conducted its survey—25,355—was twice that of prior official estimates of 10,133.[2] To meet this population’s needs, MSF, which has worked in Chad since 1982, launched medical activities (consultations and hospitalization) in Goré, Mbitoye, and Sido.

The first Central African refugees also arrived in Cameroon in January 2014.

In July 2011, the number of people who had fled CAR for Cameroon was estimated at more than 125,000.[3] Families left on foot, eating primarily leaves; manioc root; or milk and meat from their animals, slaughtered on the road when they became too weak to continue. The precarious journey took between one and four months:

“I arrived in Garoua-Boulai three days ago, but I left my village four months ago."—H., 54, a woman originally from Bouali. Testimony taken in Cameroon, June 2014.

“We left Bossantélé five months ago and we’ve been in Gbiti for two months. We left everything behind—we didn’t take anything with us. I can’t think about the future.” H., a woman originally from Bossantélé. Testimony taken in Cameroon, June 2014.

“We’ve been in Gbiti for one month. We walked for three. My son drank only milk. When the cows died, there was nothing left to eat.”—A., 30, a woman originally from Zawa. Testimony taken in Cameroon, June 2014.

“We couldn’t take anything with us. I lost everything.”—A., a woman originally from Baourou. Testimony taken in Cameroon, June 2014.

“We didn’t eat anything along the way. We only drank water.”—H., 54, a woman originally from Bouali. Testimony taken in Cameroon, June 2014.

After leaving their home villages, families tried to follow the paths trod by livestock and walked from sunrise to sunset, keeping themselves hidden to the extent possible. Unfortunately, many of them lost family members, once again, during ambushes.

MSF has been working in eastern Cameroon since the start of the year, providing assistance to Central African refugees.One, a 30-year-old woman, recalled the horror she encountered on the way: “Some people hid me, together with some of my children. My husband fled with our other children. My daughter was four. She was shot as she was walking with her father. She died.”

2. The Coffin

Some 2,599 people died, most of them in December 2013 and January 2014, most as victims of violence in CAR.

Between November 1, 2013, and April 8, 2014, the period of the MSF/Epicentre survey[4] of Sido’s refugee population, nearly 8 percent (2,599 people) of the 32,768 people who initially composed the 3,449 families questioned died. One-third of the families had lost at least one member, while 28 percent of them had lost at least two. More than half, 57 percent, of the families interviewed in Sido were originally from Bangui, the point of departure of most of the refugee convoys.

Many recounted horrifying episodes:

“We raise livestock. The anti-balakas surrounded us and set fire to our encampment. My son’s face was burned and I was burned over a large part of my body. I saw six of my children die that day.”—A Fula woman. Testimony taken in Chad, February 2014.

“The anti-balakas killed my entire family—my wife, my four children, my mother, my father, my grandfather, my older brother . . . They are all dead. My younger sister and I are the only ones left. I heard that she is at the Congo border.”—Idriss, 42, a former MSF driver in Paoua. Testimony taken in Chad, February 2014 [died on March 10, 2014].

“I was visiting my brother in M’Baiki when the anti-balakas attacked after the Sélékas left. My mother was killed in front of me . . . Some of my family is still at the Bangui airport.”—M., 16, a young woman originally from Bangui. Testimony taken in Chad, February 2014.

“The anti-Balakas burned our belongings and killed several members of my family, including my mother and my husband.”—R., 25, a woman originally from PK12 in Bangui. Testimony taken in Chad, February 2014.

“I had to leave when the anti-Balakas attacked my village. My four children were killed. I was shot in the leg and had an open fracture of the tibia. I was also wounded in the head. Three days later, I was taken to the Bangui Community Hospital. I decided to leave because of the persecution of Muslims in CAR.”—F., an elderly woman originally from Bossembélé. Testimony taken in Chad, February 2014.

Eighty-five percent of the deaths (2,208 people) occurred in CAR, before departure. Of those, more than 95 percent (2,100) were attributable to violence (bullet, knife, grenade explosion, or mortar fire). Nearly 85 percent of the victims were men (1,863). However, this violence did not spare women, children, or the elderly. Two-hundred and nine children under 15 years of age and 227 people over 60 died as a direct result of violence in CAR before departure.

Two 20-year old sisters originally from Guen recalled that, “On February 5, the anti-balakas attacked our village. There were about 100 of us gathered in a large house. They separated the men and the young boys, 45 people in total, including our husbands, and executed them in front of us. Then they mutilated the bodies.”

“Families had their throats slit," said a man originally from PK13 in Bangui. "I saw the anti-Balakas disembowel a pregnant woman; decapitate a baby.”

According to another man: “The Bouali mosque was attacked on a Friday, at 1:00PM, by the anti-balakas. I saw people killed with machetes.”

And two sisters, roughly 10 years old each, said, “Our parents were killed during the Bossembélé attack. We fled into the bush with neighbors.”

Of the 32,768 people who initially composed the 3,449 families interviewed in Sido, 4,816 (15 percent) were separated, voluntarily or involuntarily, from their family members.

“Twenty people in my family disappeared, including my husband and my eight-year-old son," said a 28-year old woman from Yaloké. "I don’t have any idea where they are and I don’t know how to look for them.”

“I am alone here with my little girl," said a 25-year-old woman from Bangui's PK5 neighborhood. "I don’t know where my husband is and I don’t have any news about my mother, who lives in Carnot.”

Others provided similar accounts of terror and loss:

“I arrived in Sido with my wife and two of my four children. My two boys, ages 20 and 15, stayed in Bangui. We lost them when our neighborhood was attacked. We don’t know where they are or how to find them.”—A., 50, a man originally from the PK5 neighborhood of Bangui. Testimony taken in Chad, February 2014.

“There was no system for choosing who would get on the truck—the people who were strong enough to climb on climbed on.”—M., 60, a man originally from Bouali. Testimony taken in Chad, February 2014.

“Two grenades hit the two trucks just behind ours. We managed to get to the Bangui airport. It was horrible. Everyone was running. I ran, too, to get onto the plane. That’s when I was separated from my brother. I haven’t had any news since then.”—M., 18, a man originally from Bangui. Testimony taken in Chad, February 2014.

The scene was chaotic as the refugees raced to board the trucks headed for Chad. The transport conditions were particularly difficult, especially for children and the elderly. With 200 to 300 people in each truck, people were suffocated and trampled. In addition, the convoys were often attacked. The trip proved fatal for 322 people. Just over 78 percent of those deaths were due to violence.

“There were a lot of vehicles and people were crammed into them. There were so many people that children suffocated.”—Testimony of a woman, taken in Chad, February 2014.

“The truck broke down along the way. The escort did not stop and the anti-balakas attacked us immediately. All the men, including our brother-in-law, were killed in front of us with machetes. Some of the women were raped. The little one [sister] was trampled. Then the anti-balakas set fire to all our belongings. They told us they were going to broil us and eat us. They left us there, in the middle of the night.”—Two sisters, around 10, originally from Bossembélé. Testimony taken in Chad, February 2014.

“In spite of the armed escort, the convoy was attacked three times in three days by rocket launchers. The Chadian army retaliated. I saw people who were following the convoy on motorcycles killed. Lots of people were wounded during the attacks."—K., 28, a woman originally from Yaloké. Testimony taken in Chad, February 2014.

“We were attacked along the way by the anti-balakas. They were perched in the trees and they shot at us. Another elderly woman who was traveling with me was wounded in the head.”—F., an elderly woman originally from Bossembélé. Testimony taken in Chad, February 2014.

“We were attacked several times on the road. The husband of one of the women I shared a hut with was killed.”—R., 25, a woman originally from PK12 in Bangui. Testimony taken in Chad, February 2014.

In Cameroon, the testimonies that MSF gathered in June from Central African refugees in the eastern part of the country also described extremely violent attacks by armed groups in CAR.

Most of the Central African refugees in eastern Cameroon are originally from rural areas around the towns of Bouar, Bossantélé, Bossangoa, Boda, Yaloké, and Baoro in western CAR. They had to flee quickly when entire villages were attacked.

“When we left, 500 other people fled at the same time," said a woman from Bossantélé. "The village is deserted now. I had no choice. I had to follow the others to survive."

While 100 people were still arriving daily in Cameroon in July, the violence continued on the other side of the border. Many refugees told MSF that they did not want to go back to CAR because of the trauma they had experienced there and out of fear of renewed clashes.

As in Chad, the refugees in Cameroon reported that many of their family members had been killed and that their families had dispersed in flight. Many are still without news of family members.

MSF psychologist Silvia Cauzzi says that the refugees were exposed to unusual levels of violence. “Their psychological trauma has a direct effect on their physical health," she explains. "They experience generalized pain, sleep problems, and loss of appetite. The mothers’ mental health also has an impact on their children, who will become ill more easily. For example, when the mother is depressed or suffering from post-traumatic shock, one of the most common consequences is that the child stops eating.”

The testimonies of refugees clearly illustrated the toll the conflict is taking on children:

“During the night there were gunshots. We were in the car. My son [10 months] fell into my arms. I shook him, I touched his belly and I saw blood. He had been shot. He died a few minutes later. We stopped the car to bury him.”—H., 30, a woman originally from Tidowa (near Bossantélé). Testimony taken in Cameroon, June 2014.

“I arrived two months ago. I fled the war in CAR. My husband was killed. My father and my two uncles were wounded by gunshots during an attack. I didn’t stop to think about what had happened.”—A., 23, a woman originally from Baourou. Testimony taken in Cameroon, June 2014.

“I had six children. Two were killed in Yaloké when the village was attacked. My oldest was killed by machete in front of me.”—H., 30, a woman originally from Yaloké. Testimony taken in Cameroon, June 2014.

“My husband is not with us. I don’t know where he is or even if he’s still alive. We tried to reach him on his telephone but he didn’t answer.”—H., a woman originally from Bossantélé. Testimony taken in Cameroon, June 2014.

“Four of my children are in Chad, but I haven’t had any news of them for a long time. I think they were all wounded during the violence in the CAR. I think my husband is also in Chad, but I’m not sure."—H., 54, a woman originally from Bouali. Testimony taken in Cameroon, June 2014.

The break-up of families also has medical consequences. The refugees, who are constantly searching for their disappeared family members, travel from one camp to the next in hopes of finding them. These constant displacements have real impacts, particularly for monitoring malnourished children, who suddenly leave the nutritional projects before being stabilized and then relapse, sometimes acutely.

3. “Trapped”

Although most of the Muslim residents of the western half of CAR left the area in just a few months, enclaves shelter those who remain. They are protected by international forces but their living conditions are very precarious.

In June 2014, the number of persons displaced by violence was estimated at 536,500,[5] of whom 20,000[6] were living in these enclaves. MSF works in three of them: in Carnot (700 displaced persons) and Berberati (350 displaced persons), in the southwest of the country; and in the PK5 neighborhood in Bangui (1,000 displaced persons who have taken shelter around the Grande Mosque).

On the grounds of the Carnot church, nearly 1,000 Muslims from different ethnic groups crowd into an area half the size of a soccer field. This crowding has become a public health issue. Half of the displaced people are children under 15 years of age. The rainy season has begun and malaria and diarrhea are widespread. “Maintaining minimal sanitary conditions in this kind of confinement is a daily challenge,” says Fabio Biolchini, MSF’s activities manager on-site. “The situation is becoming more intolerable every day. Another solution must be found quickly.”

“The living conditions are hard here. My baby died of an infection. He was just one month old.”—A woman, 20, originally from Guen. Testimony taken in Carnot, CAR, June 2014.

“Our children are sick and our women are afraid.”—A representative of the displaced Muslim community at the Carnot church. Testimony taken in Carnot, CAR, June 2014.

“Some people have been stuck in the church for several months. They have food, drink, and access to health care—thanks to MSF—but they are tired and are aging prematurely. And there’s nothing we can do.”—Muriel Masse, MSF project manager in Carnot, May 2014.

The MISCA brought these displaced persons to the Carnot church for their protection. The rest of the city is under the control of the anti-balakas. Those who venture out of the enclave are in danger.

“After the anti-balaka attack in late January, 5,000 Muslims took refuge in the Baoro church," said Dramane Kone, MSF project manager in Carnot. "They included wounded people, but it was impossible to transport them to Bouar, where MSF manages a medical-surgical program, because the anti-balakas had set up blockades along the road and would not have let them pass.

“We had to evacuate four wounded Muslims by plane from Carnot to our surgical program in Paoua," he continued. "The plane was waiting for us. Just as our ambulance set off for the airport, some 50 men, who were very tense and edgy, blocked us. We had to engage in a lengthy negotiation to get through.”

MSF has supported the hospital since 2010. Today, it is the only place in Carnot where Christians and Muslims can still mingle.

“On January 20, 2014, the ex-Sélékas reached Carnot and the thefts, pillaging, and summary executions began," Kone said. "Muslims and Christians in search of protection left their homes to gather at various sites, including the city hospital, which was considered a neutral area.”

Threatened, stripped of their property and trapped, the last Muslims in CAR had no other choice but to leave the western half of the country. On June 15, 138 adults and some 50 children thus left the Carnot church under MISCA escort. After stopping in Berberati for several days, where they swelled the ranks of displaced persons who had already arrived, they finally reached Cameroon in late June.

“Every Sunday, when it was time for mass, we were insulted and threatened," said a representative of the displaced Muslim community at the Carnot church. "The hatred is too raw to hope for reconciliation in the short-term. The only option now is to leave and wait for peace.”

“If you see a Christian, you can’t speak to him any longer and he won’t speak to you either," said a man originally from Bozoum. "Everyone is trying to save his skin. Either you attack or you’re attacked.”

In mid-May 2014, Chad decided to close its border with CAR. Now the refugees must take huge risks to cross it.

More than six months after the forced exodus of the Muslim populations from western Central African Republic began, families continue to head towards Chad, fleeing the violence. Since the convoys ended in February, they are on their own, often spending several weeks in the bush to avoid attacks, patrols, and pillaging before they manage to reach the border.

“Since mid-May, the Chadian authorities have confirmed that the border is closed to traffic from Chad to CAR, but suggest that people in distress, as well as Chadian nationals, may still enter Chad from CAR," says Sarah Chateau, MSF head of mission in Chad. "However, in the field, our teams have observed that the Sido crossing point is closed, with sporadic openings only every 10 or 15 days, allowing just 100 or so people to enter. The refugees now take huge risks to cross the border at Sido.”

In June, MSF teams recorded more than 1,700 new arrivals in Sido. They included people arriving from CAR or from other transit camps in Chad, who had come to join the family members from whom they had been separated. Some had to pay to cross or walk for hours to find more “permeable” crossing points. Others came under fire.

On June 13, four people were killed as they tried to cross the river, heading for Sido. On July 3, 100 people, victims of an attack on their village in CAR, tried to cross. At least five of them were wounded by gunfire during the attack, including a woman and three children. They had to walk for 24 hours before reaching Bethel, a Chadian border town, where MSF treated them and transported them to the Goré hospital after negotiating with the authorities, who finally approved the transfer.

Considered to be clandestine arrivals, the new refugees are not officially registered, which has an impact on their access to assistance and, in particular, to the food aid that they need.

In addition, the border closing has real consequences for the economy in the CAR border region because it has blocked the only secure commercial supply route. Merchants are also subject to new crossing "taxes,” and the price of staple foods in the Kabo and Batafango markets has tripled.

Unlike Chad, Cameroon has kept its border open. However, the assistance provided to the refugees does not come close to meeting their needs—particularly their nutritional needs.

In Garoua-Boulai, newly arrived refugees in Cameroon are assembled at a transit point where they would typically remain for a maximum of 48 to 72 hours before being transferred to an official camp. In fact, they stay there for several weeks.

In late June, for example, 1,000 people were still in this temporary camp, where living conditions continue to worsen. Near the Garoua-Boulai transit point, the IOM has set up a camp to receive nationals from third countries. More than 2,000 people are registered there. Of those, 1,700 are waiting to be transferred to Chad, their country of origin, which for now refuses to accept more refugees or nationals.

The nutritional status of the refugee populations is particularly worrisome. In Gado and Gbiti, where MSF is working, 20 percent of the total refugee population of 16,500 (3,300 people) are children under five years of age. As of late June, 1,320 children had moderate malnutrition and 198 had severe malnutrition. At MSF’s intensive therapeutic feeding treatment centers, 10 to 15 percent of the children are over five years of age, a sign that the nutritional situation is critical.

Although several thousand people are living in the official camps, the refugee population remains very dispersed in eastern Cameroon. Part of that population prefers to live in Cameroonian villages or in the forest, with their family members who are already settled in the country, but they lack access to medical care and assistance, particularly food aid, that is available in the official camps.

An MSF assessment conducted in late June identified a pocket of 230 refugees living in a village without any assistance. Others try to settle in border towns and refuse to be moved to the camps, which would prevent them from conducting trade near the border. Eight-thousand four-hundred displaced persons have thus settled in Garoua-Boulai, rather than in the camps.

Further south, 26,000 people were registered at the Gbiti entry point, but most are already gone. Those who remain in Gbiti hope to be transferred to the camps soon. This dispersal makes it difficult to assess the exact number of refugees in Cameroon and, thus, to plan, organize, and set up a humanitarian response.

Despite the mobilization of new aid actors, the Central African refugees in Cameroon need additional humanitarian aid. It must expand to cover more needs (access to water, food, medical care, and shelter) and be deployed where the refugees are located—whether in formal camps, transit points, villages, the bush, or informal gathering sites.

MSF in CAR

MSF has been present in CAR since 1997. More than 300 international staff and 2,000 locally hired staff work for MSF in medical and surgical programs in 15 towns in CAR. The teams provide assistance to victims of violence in Bangui and the rest of the country, regardless of their ethnic origin or religious affiliation. MSF is also present in Central African refugee camps in Chad and Cameroon.

Appendix 1: THE FRAMEWORK OF THE RETROSPECTIVE MORTALITY SURVEY CONDUCTED BY EPICENTRE/MSF IN SIDO, CHAD

Following alarming testimonies gathered by MSF teams in Chad in February 2014, MSF took advantage of the epidemiological surveillance system set up by Epicentre to collect more precise information on the Central African refugee populations in Sido.

Between March 26 and April 8, 2014, Epicentre conducted an exhaustive retrospective mortality survey. The main objective was to determine mortality among the Central African refugees in Sido during the study period November 1, 2013, to April 8, 2014.

The target population was made up of all the 3,449 families in Sido, initially totaling 32,768 people, including 25,353 (the majority women and children) who arrived in Sido following the violence in CAR in late 2013/early 2014. More than half of the families (57 percent) were originally from Bangui, the point of departure of most of the refugee convoys.

Survey findings

The number of refugees in Sido was under-estimated

The number of people in the Sido region during the survey (23,355) was twice that of official prior estimates (10,133).

Mortality rates were very high

Of the 32,768 people who initially composed the 3,449 families interviewed, nearly 8 percent (2,599 people) died in the CAR during the trip to Chad or in Sido.

Thirty-three percent of the families interviewed lost at least one member of their family; 27.6 percent lost at least two.

Violence was the leading cause of death prior to departure and during the trip

Of the 2,208 total deaths recorded in the CAR, 95.6 percent are due to violence (gunshot, knife, grenade explosion or mortar fire); 84 percent of the deaths involved men and, specifically, those between 33 to 44 years of age.

Of the 322 deaths recorded during the trip to Chad, 78.3 percent were due to violence.

Families were split apart

Of the 20,060 people who sought refuge in Sido between November 2013 and April 2014, 48.7 percent arrived in January and 36.6 percent in February 2014.

Of the 32,768 people who initially composed the 3,449 families interviewed, 4,816 (15 percent) were separated, voluntarily or not, from their family members.